The True Value of Video Laryngoscopes

Ask Mike MacKinnon, DNP, FNP-C, CRNA, about the benefits of video laryngoscopes, and he’s likely to tell you about a specific case he did several years ago. Dr. MacKinnon, an anesthesia provider for Northeastern Anesthesia in Show Low, Ariz., was working a laparoscopic appendectomy, an extremely common outpatient procedure, and getting ready to intubate a male patient in their early 40s with an ASA physical status of one. The patient’s airway exam proved unremarkable; he was able to open his mouth wide and he could complete an upper lip bite test.

Dr. MacKinnon assumed the case would proceed without incident, like the thousands he’s done before. But this patient had also never had anesthesia, and everything changed during the intubation. An abnormal epiglottis covered the patient’s airway and made it impossible to see, and therefore intubate, with the laryngoscope’s blade.

“There was a moment there when I thought, ‘Man, am I going to have to wake the patient up and abort the case?’” says Dr. MacKinnon. Luckily, the facility had a video laryngoscope, which they brought into the room and he was able to better see and manipulate the airway to intubate the patient. In the end, everything worked out. “The case was completed as planned,” says Dr. MacKinnon.

The entire incident highlighted a fundamental truth about providing anesthesia to ambulatory surgery patients. “In the outpatient surgery world, it’s those totally unexpected patients who make video laryngoscopes invaluable,” says Dr. MacKinnon.

Video laryngoscopy allows anesthesia providers to view the patient’s larynx indirectly on a video monitor and offers a number of advantages over direct laryngoscopy, especially when it comes to difficult intubation cases like the one mentioned earlier. “Video laryngoscopes magnify the view on screen,” says Michael Aziz, MD, a professor of anesthesiology and perioperative medicine at Oregon Health & Science University’s School of Medicine in Portland. “Instead of one person looking through an opening the size of a keyhole, the entire operating room team can watch the intubation on a small or large screen, which improves engagement in the process.”

With more than one person viewing the video screen, either the circulating nurse or another anesthesia provider can manipulate the larynx to improve the endotracheal tube passage, says Dr. Aziz. Plus, he says, when providers can anticipate difficult airway situations in advance, video laryngoscopy can reduce the number of intubation attempts, improve first-attempt intubations, reduce failure rate and lessen the overall difficulty of intubating patients.

Video laryngoscopes have become exceedingly intuitive and user-friendly with a learning curve that is far less steep than direct laryngoscopy, according to many experts. For instance, Irene Osborn, MD, says providers must go through extensive training and 60 intubations to be proficient in the use of a traditional blade on a direct laryngoscope. “To learn how to use a video laryngoscope, you have to do about 20 intubations,” says Dr. Osborn, director of neuro-anesthesia at Montefiore Medical Center and professor of anesthesiology at Albert Einstein College of Medicine in Bronx, N.Y. “In my experience, they are so much easier to use.”

Providers who use video laryngoscopes regularly swear by them and ultimately see the technology completely overtaking direct laryngoscopy. “I use video laryngoscopes every day,” says Dr. Osborn. “As they become less expensive and easier to use and we gain the skills, I think in another 10 years they’re going to replace direct laryngoscopy. I think we’re definitely in a transition phase.”

The pandemic seemed to expedite this transition as video laryngoscopy became a universal means of reducing the risk of COVID-19 transmission to healthcare providers and many wondered if this technology had turned a corner to become the standard of care. That doesn’t appear to be the case just yet. “Everyone should be taking the standard universal precautions they always were, but does it really mean we always need to use a video laryngoscope in outpatient surgery post-COVID?” says Dr. MacKinnon. “I don’t think it does.”

Like any technology that can enhance or improve the quality of care in the OR, there’s an added cost — a price tag that can be prohibitive for some facilities, particularly smaller centers with even smaller margins. But technological advances and marketplace competition have led to some significant drops in video laryngoscopes pricing in recent years. Dr. Osborn says the latest models have dropped to less than $10,000, and you can even purchase smaller, more portable scopes for approximately $2,000.

The more expensive high-end video scopes can cost as much as $30,000, but the cost of the device itself isn’t necessarily the issue. “It’s the disposable costs that really add up,” says Dr. MacKinnon.

Disposable blades cost about $8 a piece and can prevent video laryngoscopes from being cost-effective for some facilities. But before you rule out investing in these devices based on price alone, understand that vendors often offer additional purchasing options.

“You can get a contractually free video laryngoscope from a vendor as long as you use a certain number of disposable blades per quarter or per year,” says Dr. MacKinnon. “Those contracts exist in both hospitals and surgery centers.”

But if you go that route, you have to be sure you can meet the purchasing requirements, he points out. Determining your numbers is a critical part of deciding how many video laryngoscopes your facility will need, and you must be cognizant of the specific cost-ratio benefit with which you’re dealing. “When you’re making the purchasing decisions, determine exactly what your needs are,” says Dr. McKinnon. “Are you intubating 10 people per day, five people per day or almost none?”

“If you’re running a four- or five-room surgery center with a lot of intubations, then it makes sense to equip your facility with at least a couple video scopes — if not one for each OR,” according to Dr. McKinnon. Of course, the opposite is true, as well. If you’re running a three-OR surgery center that’s mainly using laryngeal mask airways (LMAs) to secure difficult airways, do you really need a video laryngoscope in each OR? “Probably not, but you should absolutely have at least one available,” says Dr. MacKinnon.

Surgeons expect you to do what you need to do, which is secure the airway.
— Irene Osborn, MD

The availability of a video laryngoscope could mean the difference between completing a case, not completing the case or a negative outcome, says Dr. MacKinnon. Obviously, a negative outcome is the worst-case scenario that must be avoided at all costs, but being unable to complete a case because of a failed intubation is a headache no busy, successful facility should have to deal with when it could easily be avoided.

“No one wants to cancel a case because you couldn’t intubate the patient,” says Dr. Osborn. “Surgeons expect you to do what you need to do, which is secure the airway.”

Ultimately, video laryngoscope usage is all about providing safer patient care, something for which every anesthesia provider strives. “It’s always within our mindset to do all we can to reduce the risk of morbidity and mortality,” says Dr. Aziz. “I think video laryngoscopy achieves that goal.” OSM